Hamid R. Zahiri

Incisional negative-pressure wound therapy versus conventional dressings following abdominal wall reconstruction: a comparative study.

BackgroundImprovements in surgical techniques have allowed us to achieve primary closure in a high percentage of large abdominal hernia repairs. However, postoperative wound complications remain common. The benefits of negative-pressure wound therapy (NPWT) in the management of open abdominal wounds are well described in the literature. Our study investigates the effects of incisional NPWT after primary closure of the abdominal wall. MethodsA retrospective chart review was performed for the period between September 2008 and May 2011 to analyze the outcomes of patients treated postoperatively with incisional NPWT versus conventional dry gauze dressings. Patient information collected included history of abdominal surgeries, smoking status, and body mass index. Postoperative complications were analyzed using &khgr;2 exact test and logistic regression analysis. ResultsFifty-six patients were included in this study; of them, 23 were treated with incisional NPWT, whereas 33 received conventional dressings. The rates of overall wound complications in groups I and II were 22% and 63.6%, respectively (P = 0.020). The rates of skin dehiscence were 9% and 39%, respectively (P = 0.014). Both outcomes achieved statistical significance. Rates of infection, skin and fat necrosis, seroma, and hernia recurrence were 4%, 9%, 0%, and 4% for group I and 6%, 18%, 12%, 9% for group II, respectively. ConclusionsThis study suggests that incisional NPWT following abdominal wall reconstruction significantly improves rates of wound complication and skin dehiscence when compared with conventional dressings. Prospective, randomized, controlled studies are needed to further characterize the potential benefits of this therapy on wound healing after abdominal wall reconstruction.

Prevention of 3 “Never Events” in the Operating Room: Fires, Gossypiboma, and Wrong-Site Surgery

Background: This study sought to identify and provide preventative recommendations for potentially devastating safety violations in the operating room. Methods: A Medline database search from 1950 to current using the terms patient safety and operating room was conducted. All topics identified were reviewed. Three patient safety violations with potential for immediate and devastating outcomes were selected for discussion using evidence-based literature. Results: The search identified 2851 articles, 807 of which were directly related to patient safety in the operating room. Topics addressed by these 807 included infectious complications (26%), fires (11%), communication/teamwork (6%), retained foreign objects (3%), safety checklists (1%), and wrong-site surgery (1%). Fires, gossypiboma, and wrong-site surgery were selected for discussion. Conclusions: Although fire, gossypiboma, and wrong-site surgery should be “never events” in the operating room, they continue to persist as 3 common patient safety violations. This study provides the epidemiology, common etiologies, and evidence-based preventative recommendations for each.

Significant predictors of complications after sternal wound reconstruction: a 21-year experience.

BackgroundWe sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction. MethodsA retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson &khgr;2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P ⩽ 0.05. ResultsIn all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P = 0.014, 0.012, and 0.006). ConclusionsResults suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

A Modified Approach to Component Separation Using Biologic Graft as a Load-Sharing Onlay Reinforcement for the Repair of Complex Ventral Hernia

Background. Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure. Methods. This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences. Results. There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation. Conclusions. This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.

The Sentinel Fat Pads: The Relationship of the ROOF and SOOF to the Temporal Nerve in Facial Rejuvenation

BACKGROUND A great number of studies have reported on the temporal branch anatomy and its relationship to the fascial layers and various fat pads of the temporal region, but no article has included information on the relationship of the temporal nerve to the retro-orbicularis oculi fat (ROOF) and/or the suborbicularis oculi fat (SOOF). OBJECTIVES The authors report the results of a series of human cadaver temporal nerve dissections, with particular attention paid to its relation to the ROOF and the SOOF. The results of a literature review and a subsequent open browlift are also reported to confirm the results of the cadaver study. METHODS Dissection was performed on 15 fresh human cadavers, for a total of 29 hemifaces. The course and relationships of the temporal nerve branch to the fascia, fat pads, and landmarks in the temporal region were noted and detailed. A thorough review was also performed for 23 articles, to compare the authors anatomical findings with data in the previous literature. RESULTS During cadaver dissection, the temporal branch was found to lie on the undersurface of the superficial temporal fascia. In the supraorbital area, the ROOF existed in the loose areolar plane or deep layer of the superficial temporal fascia, with the temporal nerve branch directly superficial to it. The temporal branch passed lateral to the SOOF in its superiomedial course at the level of the zygoma. These findings were later confirmed during an in vivo open browlift as well. CONCLUSIONS The ROOF was formerly unrecognized as an important sentinel marker for possible injury to the temporal nerve branch during browlift. However, this cadaver study and its accompanying literature comparisons show that browlift dissection, whether endoscopic or open, should aim to keep the ROOF fat in the superficial plane, ensuring that the nerve branch is safe from iatrogenic injury.

Pectoralis major turnover versus advancement technique for sternal wound reconstruction.

BackgroundWe compared the efficacy of pectoralis turnover versus advancement technique for sternal wound reconstruction. MethodsA retrospective chart review was performed, December 1989 to December 2010, to compare postoperative complication rates between pectoralis major turnover versus pectoralis major advancement reconstruction techniques. Complications included hematomas, wound infections, tissue necrosis, dehiscence, and need for reoperation. Pearson &khgr;2 and logistic regression were used and significance was P < 0.05. ResultsSixty-seven patients received 91 tissue flaps. Eleven patients (16%) required reoperation due to complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Four patients (6%) were treated conservatively for minor complications. Overall, complication rates were significantly higher after pectoralis major advancement reconstruction (32.5% vs. 3.7%, P = 0.004). ConclusionsWhen feasible, pectoralis major turnover flap offers a superior reconstructive technique for complex sternal wounds, with diminished complications compared with the pectoralis advancement flap.

Porcine acellular dermal matrix (PADM) vascularises after exposure in open necrotic wounds seen after complex hernia repair

Biological alternatives to synthetic meshes are increasingly utilised in complex abdominal wall reconstruction. There is a lack of evidence demonstrating that non‐cross‐linked porcine acellular dermal matrix vascularizes and integrates with human tissue in suboptimal wound conditions. We aimed to evaluate these properties in Strattice™ (Life Cell Inc., Branchburg, NJ) following ventral hernia repair. A retrospective review of patients with high‐risk ventral hernia repair utilising Strattice™ as an onlay after open component separation was conducted. Patients with postoperative wound exploration and exposure of the onlay were included in this review. One patient underwent punch biopsy for histological analysis. Eleven patients with wound complications necessitating postoperative debridement and exposure of Strattice™ onlay were identified. The onlay was partially debrided in two cases, and one case required complete excision. Vascularisation was clinically evident in 10 of 11 cases (91%) as demonstrated by the presence of granulation tissue and/or the ability to support a skin graft. Histological analysis of one onlay 3 months postoperatively showed neovascularisation and collagen remodelling with minimal inflammatory response. Strattice™ demonstrated resistance to rejection, ability to undergo vascularisation and incorporation into host tissues in sub‐optimal wound conditions following ventral hernia repair.

Transoral submucosal resection of the inferior turbinate: a novel approach to functional rhinoplasty.

Background:In the presence of turbinate dysfunction, an inferior turbinectomy for persistent hypertrophy of bone and/or mucosa may be performed. We sought to explore anatomic feasibility of a transoral turbinectomy. Methods:After transoral inferior turbinectomy in 12 cadavers, average distances from the external nasal valve to inferior turbinate and from pyriform aperture to inferior turbinate were compared. Average “area of access” was calculated. Preoperative and postoperative nasal length, tip projection, and alar-base width were also compared. Results:Average distance from external nasal valve to inferior turbinate was 32.4 mm. Average distance from aperture to inferior turbinate was 2.4 mm (P < 0.0001). Average “areas of access” to nasal vault through the external nasal valve and mouth were 183.9 mm2 and 243.6 mm2 (P = 0.07), respectively. Conclusions:The transoral approach provides a larger “area of access” to the turbinate, a statistically significant reduction of distance to target, no postoperative changes in nasal soft tissue, and easier instrumentation.

Pectoralis Major Turnover Versus Advancement Flap for Sternal Wound Reconstruction: A 21-Year Experience

concluSIon: DIEP flaps appear to be as profitable as pTRAM flaps with lower morbidity. The transition from pTRAM to perforator flaps can be done successfully with well-trained microsurgeons, an already established breast reconstruction practice, and support from leadership and hospital staff. We believe that the development of a perforator flap practice represents an opportunity cost in optimizing patient care, and should be an option available to patients seeking autologous breast reconstruction. Pectoralis Major Turnover Versus Advancement Flap for Sternal Wound reconstruction: A 21-year Experience